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Ocular manifestations of torture: solar

retinopathy as a result of forced solar gazing
J Polat, E Feinberg and S S Crosby

Br J Ophthalmol published online June 24, 2010

doi: 10.1136/bjo.2009.171595

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http://bjo.bmj.com/content/early/2010/06/23/bjo.2009.171595.full.html#ref-list-1

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BJO Online First, published on June 24, 2010 as 10.1136/bjo.2009.171595
LETTER
Ocular manifestations of torture:
solar retinopathy as a result
of forced solar gazing
Solar retinopathy as a result of sun gazing
has been well documented and occurs as
a result of thermal and photochemical
processes after solar exposure.1 Although
solar exposure is usually a result of deliberate
sun gazing, forced sun gazing can also be
used as a torture method.
Torture is prevalent worldwide. In 2007,
the Amnesty International documented
cases of “torture and other cruel, inhuman or
degrading treatment” in 81 countries.2
It is important for clinicians to be aware
of the physical manifestations of torture
because they are not always obvious. Torture
methods are often devised to leave minimal
long-term physical indications but often
have tremendous psychological impact.3
Survivors will often not disclose the experi-
ence of their torture with their physician,
and the diagnosis may be missed.4
CASE
A 58-year-old West African man was referred
to an ophthalmology clinic by his primary
care physician with a chief complaint of
difficulty reading and discomfort and blur on
more than momentary reading. His medical
history included torture in Cameroon 3 years
earlier. On two consecutive days, he was
taken from his cell and at gunpoint forced to
stare at the sun for a duration that he be-
lieves was about an hour each day. He
possessed no means for measuring time. He
was threatened with death if he looked away
or closed his eyes, and did observe the
execution of another prisoner for failure to
comply. He described great pain and blurred
vision afterwards, but he felt that he recov-
ered and was able to see well at close range
and distance until recently when he devel-
oped difficulty reading.
On examination, the distance visual acuity
was 20/20 in both eyes on the Snellen test
without correction. Uncorrected near acuity
was J7 in either eye. With appropriate pres-
byopic correction, his near vision improved to
J0 in both eyes. Fundus examination of the left
eye showed an atrophic area with pigment
migration, shaped like two overlapping
circles, approximately 1 mm in diameter. On
retinal photographs, the lesion was exactly
the same distance temporal to the fovea as the
disc was nasal to the foveal umbo (see figure
1). The right fundus was normal. The visual
fields were normal.
Polat J, Feinberg E, Article
Copyright Crosby SS.author
Br J Ophthalmol (2010). employer)
(or their
Figure 1 Fundi of patient showing scar temporal to the fovea in left eye secondary to solar burn.
Diagnostic impressions were presbyopia in
both eyes and solar burn in left eye secondary
to torture by forced sun gazing. The
appearance of the lesion is classic for the late
lesion of solar gazing after the initial oedema
of the neurosensory retina has faded. The
patient was certain that he had looked
directly at the sun, but the location of the
unilateral burn suggested that he had instead
instinctively arranged his gaze to place the
image on the optic nerve head oculus dexter
and temporal to the fovea oculus sinister to
minimise pain. Because there was no optic
atrophy, the lighter colour of the optic nerve
presumably converted less light energy to
heat than the darker fundus, including the
retinal pigment epithelium and the choroidal
pigment, and optic nerve tissue was not lost.
In addition, the size of the extrafoveal lesion
is comparable with the foveal lesions of
patients seen with solar injury to the fovea.5
Treatment with presbyopic correction elim-
inated his presenting symptoms.
DISCUSSION
In this report, we document that forced sun
gazing can also be used as a physical torture
method, which can result in solar retinop-
athy. Psychological sequelae may also be
present in torture survivors, such as symptoms
of post-traumatic stress disorder and major
depression. If a physician identifies a patient
as being a survivor of torture, it is important
for them to be aware of programmes that
specialise in the care of torture survivors
such as the International Rehabilitation
Council for Torture Victims.6
In summary, this is a unique report of
forced sun gazing used as a torture method
and resulting in solar retinopathy. Unlike
with deliberate sun gazing, where solar
burns are usually located foveal or perifoveal,
torture victims may shift their eyes, causing
solar burns offset from the retina. In the case
presented in this report, an affidavit and
testimony were given in court documenting
doi:10.1136/bjo.2009.171595
2010. Produced
by BMJ Publishing Group Ltd under licence.
PostScript
the ophthalmic findings, which contributed
to the patient being granted political asylum.
J Polat,1 E Feinberg,2 S S Crosby3,4
1
University School of Medicine, Boston, Massachusetts,
USA; 2Department of Ophthalmology, Boston University
School of Medicine, Boston, Massachusetts, USA;
3
Department of Medicine, Boston University School of
Medicine, Boston, Massachusetts, USA; 4Department of
Health Law, Bioethics and Human Rights, Boston
University School of Public Health, Boston,
Massachusetts, USA
Correspondence to S S Crosby, Section of General
Internal Medicine, Boston Medical Center, Crosstown 2,
801 Massachusetts Avenue, Boston, MA 02118, USA;
scrosby@bu.edu
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the
approval granted by the institutional review board of the
Boston University School of Medicine.
Provenance and peer review Not commissioned;
externally peer reviewed.
Accepted 20 December 2009
Br J Ophthalmol 2010;-:1.
doi:10.1136/bjo.2009.171595
REFERENCES
1. Istock TH. Solar retinopathy: a review of literature and
case report. J Am Optom Assoc 1985;56:374e81.
2. Amnesty International. Amnesty International report
2008: at a glance. 2008:http://archive.amnesty.org/
air2008/eng/facts-and-figures.html (accessed 30 Jun
2009).
3. Iacopino V, Allden K, Keller A. Examining asylum
seekers: a health and professional’s guide to medical
and psychological evaluations of torture. Boston:
Physicians for Human Rights, 2001.
4. Miles SH, Freedman AM. Medical ethics and torture:
revising the declaration of Tokyo. Lancet
2009;373:344e8.
5. Yannuzzi LA, Fisher YL, Krueger A, et al. Solar
retinopathy: a photobiological and geophysical analysis.
Trans Am Ophthalmol Soc 1987;85:120e58.
6. International Rehabilitation Council for Torture Victims.
http://www.irct.org/ (accessed 2 Jul 2009).
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